| Notification of Changes for Business Entity |
| General Information | |
| Business Entity Name: | DERVIN INSURANCE GROUP, INC |
| Incorporation / Formation Date: | 04/06/1966 |
| FEIN: | 34-0975394 |
| Ohio License Number: | 960 |
| NPN: | 2557680 |
| DBA / Trade Name: | PRETORIUS INSURANCE AGENCY |
| State of Domicile: | OH |
| County: | TUSCARAWAS |
| Business Address | |
| Address 1: | 715 N WOOSTER AVE |
| Address 2: | |
| City: | DOVER |
| State: | OH |
| Zip: | 44622 |
| Phone: | 330-343-7122 |
| Fax: | |
| Business Web Site Address: | WWW.PRETORIUSINSURANCE.COM/WWW.DERVININSGROUP.COM |
| Business Email Address: | AMYDERVIN@PRETORIUSINSURANCE.COM |
| Mailing Address | |
| Address 1: | 1515 PORTAGE ST NW SUITE F |
| Address 2: | |
| City: | NORTH CANTON |
| State: | OH |
| Zip: | 44720 |
| | |
| Indicate the type of change you are seeking |
| Address Change: | NO |
| Business Entity Name Change: | YES | Old Business Entity Name: | PRETORIUS AGENCY INC |
| New DBA/Trade Name: | NO | New DBA/Trade Name: | |
| Amend DBA/Trade Name: | NO | Old DBA/Trade Name: | |
| Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors: | NO |
| | |
| Title Business Entities Only |
| 1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company) |
| 2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application? |
| 3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement | |